Sustainability and transformation plans (STPs) are five year plans detailing how local areas will work together to implement the ‘Five Year Forward View’ and achieve financial balance by 2020. STPs will be the main gateway to funding from 2017/18.

For these plans to be developed, England has been divided into 44 STP geographic ‘footprints’ made up of NHS providers, CCGs, local authorities and other health and care services. These organisations will work together to create a plan based on local health needs.

The average population size for a STP is 1.2 million people (the smallest area covers a population size of 300,000 and the largest 2.8 million). A named individual has been chosen to lead the development of each STP.

The proposed scope of STPs is broad, however, there are three headline areas: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. The timelines for developing STPs and the process for approving them have been somewhat fluid. The plans are likely to be assessed and approved in phases, depending on their quality. From April 2017, STPs will become the single application and approval process for accessing NHS transformation funding, with the best plans set to receive funds more quickly.

What do the STP mean for NHS?

STPs represent a shift in the way that the NHS in England plans its services. While the Health and Social Care Act 2012 sought to strengthen the role of competition within the health system, NHS organisations are now being told to collaborate rather than compete to respond to the challenges facing their local services. This new approach is being referred to as place-based planning.

This shift reflects a growing consensus within the NHS that more integrated models of care are required to meet the changing needs of the population. In practice, this means different parts of the NHS and social care system working together to provide more co-ordinated services to patients – for example, by GPs working more closely with hospital specialists, district nurses and social workers to improve care for people with long-term conditions.

It also recognises that the growing financial problems in different parts of the NHS can’t be addressed in isolation. Instead, providers and commissioners are being asked to come together to manage the collective resources available for NHS services for their local population

But developing STPs is not a simple task. STP footprints are often large and involve many different organisations, each with their own cultures and priorities. Perhaps the biggest challenge facing leaders is that STPs are being developed in an NHS environment that was not designed to support collaboration between organisations. Leaders of NHS providers, for instance, find themselves under significant pressure from regulators to improve organisational performance. This means focusing primarily on their own services and finances rather than working with others for the greater good of the local population.

Will STP be beneficial to local population?

This will depend on finalised STP plans. However, the aim to integrate health and social care services more closely and to provide a platform for improving population health is laudable.

There are some reasons to be cautious about the kind of benefits that will be delivered. For example, concerns have been raised that leaders have focused their efforts on plans for reconfiguring acute hospital services, despite evidence that major acute reconfigurations rarely save money and can fail to improve quality too (and in some cases, even reduce it).

However, STPs could provide a foundation for a new way of planning and providing health services based around the needs of local populations. While STPs are primarily being led by the NHS, developing credible plans will require the NHS to work in partnership with social care, public health and other local government services, as well as third sector organisations and the local community.

It came into being on 1st Apr 2016. It is the operational name for an organisation that brings together:

Monitor

NHS Trust Development Authority

Patient Safety, including the National Reporting and Learning System

Advancing Change Team

Intensive Support Teams

NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. It offers the support these providers need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. By holding providers to account and, where necessary, intervening, it help the NHS to meet its short-term challenges and secure its future.

Currently, NHS is under severe pressure. More is asked of NHS every year as the population grows and changes. The public funding for NHS is not growing so fast. A lot of NHS trusts and foundation trusts are facing big challenges. Their task is to meet the nation’s healthcare needs within the NHS budget. How can they extend services and maintain or improve the quality of what they do and at the same time keep a lid on the cost. The answer is to work together with the local communities, other NHS and social care organisations in remodelling local health care systems. With everyone’s input systems can be designed to deliver high-quality affordable care indefinitely but none of this is easy.

NHS improvement works alongside NHS trusts and foundation trusts to help them overcome these challenges. NHS Improvement supports their efforts to

Care quality

Operational efficiency &

Financial management

NHS improvement also holds trusts to account in meeting national standards in all these areas. NHS improvement as part of their statutory duty intervenes in Trusts which can’t meet these standards to protect and promote the interests of people who use health care services. As sector regulators, NHS improvement also sets the rules determining the tariffs for NHS services and make sure that procurement, choice and competition operate in patient’s best interests.

NHS Improvement helps the trust help themselves in 3 main ways:

First, they provide the board members and managers with more of the skills, systems and information they need to prevent, pre-empt and tackle their particular issue and to continuously improve.

Second, they give trusts practical evidence-based help. They advise on how to make services more efficient without eroding quality for instance by managing waiting list differently. They can suggest on how to improve clinical quality without overspending. NHS improvement tries hard to avoid duplicating. Their first instinct is to check what expertise is out there and link people together so they are a hub for sharing existing good practice and knowledge across the sector

Third, NHS Improvement spells out what success looks like for the trusts so that everyone knows what they are aiming for and how to measure progress.

NHS improvement work with other national partners at the centre of the health system like NHS England and the Care quality commission to make sure they all speak with one voice to the sector and the individual messages and actions are consistent.

Consultant Outcomes Publication (COP) is an NHS England initiative, managed by HQIP (Healthcare Quality Improvement Partnership), to publish quality measures at the level of individual consultant doctor using National Clinical Audit and administrative data. The data is published on NHS choices website (http://www.nhs.uk/service-search/performance/Consultants#view-the-data).

The information published so far includes how many times each participating consultant has performed certain procedures and what their mortality rate is for those procedures. The data shows where the clinical outcomes for each consultant sit against the national average. The data is risk adjusted to ensure outcomes are calculated as if all consultants operated on the ‘average’ patient.

The aim of COP is to drive up the quality of care in the NHS and improve transparency.

Prof Sir Bruce Keogh, National Medical Director of NHS England, said: ‘We know from our experience with heart surgery that putting this information into the public domain can help drive up standards. That means more patients surviving operations and there is no greater prize than that’.

The reporting of the data was led by Prof Ben Bridgewater from the Healthcare Quality Improvement Partnership (HQIP). Prof Bridgewater is a practising heart surgeon who leads the successful cardiac consultant-level reporting which paved the way for this work.

Prof Bridgewater said: ‘Ultimately there is one patient and one responsible consultant. This means the public can now know about the care given by each doctor and be reassured an early warning system is in place to identify and deal with any problems

Due to data protection legislation, consultants had to agree to have results from their operations published and around 98% have. The names of those consultants who have not agreed to have data published and the trusts they work in can be seen on NHS choices website.

Some surgeons object to the principle of attributing surgical results to an individual when those results are dependent on effective teamwork between surgeon, anaesthetist, theatre and ward nurses and physiotherapists. Prof Sir Bruce Keogh counters that the patient enters the agreement for surgery with the surgeon and someone has to be accountable for the team’s outcomes.

What will the NHS do where consultants have high mortality rates?

Any hospital or consultant identified as an outlier will be investigated and action taken to improve data quality and/or patient care.

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The General Medical Council (GMC) (with eight UK professional healthcare regulators) has underlined its commitment to a professional duty of candour for doctors in a statement issued in Oct 2014

Health professionals must be open and honest with patients when things go wrong. This is also known as ‘the duty of candour’.

Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.

This means that healthcare professionals must:

•tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong;

•apologise to the patient (or, where appropriate, the patient’s advocate, carer or family);

•offer an appropriate remedy or support to put matters right (if possible); and

•explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.

‘The awful reality that emerged from Mid Staffs and indeed other inquiries was that doctors knew about GMC guidance but were not empowered by it. They felt it was acceptable to ‘walk by the other side of the ward’ knowing that there was unsafe and unacceptable practice going on. We must all do what we can to make sure that does not happen again. The statement above is an important milestone and makes it clear that the professional duty of candour sits with every healthcare professional, regardless of their field of practice.

The government in Nov 2014 has introduced a further duty of candour on secondary care organisations registered with CQC – one required, and enforceable, by law.

This new statutory duty of candour will apply to all other care providers registered with CQC from 1 April 2015. The key principles are:

1. Care organisations have a general duty to act in an open and transparent way in relation to care provided to patients. This means that an open and honest culture must exist throughout an organisation.

2. The statutory duty applies to organisations, not individuals, though it is clear from CQC guidance that it is expected that an organisation’s staff cooperate with it to ensure the obligation is met.

3. As soon as is reasonably practicable after a notifiable patient safety incident occurs, the organisation must tell the patient (or their representative) about it in person.

4. The organisation has to give the patient a full explanation of what is known at the time, including what further enquiries will be carried out. Organisations must also provide an apology and keep a written record of the notification to the patient.

5. A notifiable patient safety incident has a specific statutory meaning: it applies to incidents where a patient suffered (or could have suffered) unintended harm that results in death, severe harm, moderate harm or prolonged psychological harm.

6. There is a statutory duty to provide reasonable support to the patient.

7. Once the patient has been told in person about the notifiable patient safety incident, the organisation must provide the patient with a written note of the discussion, and copies of correspondence must be kept.

Doctors are most likely to be the organisation’s representative under the statutory duty. It is important that you cooperate with your organisation’s policies and procedures, including the requirement to alert the organisation when a notifiable patient safety incident occurs.

An area of difficulty may be deciding whether an incident reaches the threshold for notification under the statutory duty. This may be confusing, as the threshold is low for the doctor’s ethical duty (any harm or distress caused to the patient) while the thresholds for the contractual and statutory duties are higher and slightly different (at least moderate harm).

Urgent and emergency care services face profound pressures that are most obviously experienced by patients and clinicians working in emergency departments and acute admission wards.

The Royal College of Physicians, the College of Emergency Medicine and the Royal Colleges of Surgeons and of Paediatrics and Child Health have produced a joint report, Acute and emergency care: prescribing the remedy, which provides 13 comprehensive local and national recommendations to address these challenges and to build safer, more effective and efficient urgent and emergency care services for all patients.

The recommendations are:

Every emergency department should have a co-located primary care out-of-hours facility- It is unreasonable to expect patients to determine whether their symptoms reflect serious illness or more minor conditions. Co-location enables patients to be streamed following a triage assessment.

Best practice that directs patients to the right care, first time, should be promoted across the NHS so as to minimise repetition of assessment, delays to care and unnecessary duplication of effort. Examples of best practice include: stroke patients being transferred directly to stroke Units, medical patients who have been assessed by a GP being taken directly to the medical admissions unit, patients with post-operative complications being returned to surgical care, GP-to-consultant advice lines, easy access to urgent clinics etc

All trainee doctors on acute specialty programmes should rotate though the emergency department.

Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception. It should include acute physicians, acute paediatricians, GPs, emergency care physicians, geriatricians and psychiatrists.

Emergency departments should have the appropriate skill mix and workforce to deliver safe, effective and efficient care. Where an emergency department does not have onsite back-up from particular specialties, there should be robust networks of care and emergency referral pathways.

At times of peak activity, the system must have the capacity to deploy or make use of extra senior staff.

Community and social care must be coordinated effectively and delivered 7 days a week to support urgent and emergency care services. The aim should be to facilitate the safe discharge and timely transfer of care of patients from the hospital to their own home or usual place of residence.

Community teams should be physically co-located with the emergency department to bridge the gap between the hospital and primary and social care, and to support vulnerable patients. Co-located teams should include primary care practitioners, social workers and mental health professionals.

The delivery of a seven-day service in the NHS must ensure that emergency medicine services are delivered 24/7, with senior decision makers and full diagnostic support available 24 hours a day, including appropriate access to specialist services. This will require additional resources.

The funding and targets systems for emergency department attendances and acute admissions are unfit for purpose and require urgent change.

It is essential that each emergency department and acute admissions unit has an IT infrastructure that effectively integrates clinical and safeguarding information across all parts of the urgent and emergency care system.

If configured properly with significant clinical involvement and advice, NHS 111, NHS 24, NHS Direct and equivalent telephone advice services can help to reduce the pressures on the urgent and emergency care system.

The NHS Five Year Forward View was published on 23rd Oct 2014. It sets out a vision for the future of the NHS. It was developed by the partner organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority.

The purpose of the Five Year Forward View is to articulate why change is needed, what that change might look like and how we can achieve it. This was the first time the NHS as a whole had set out its vision to government rather than vice versa

Why change is needed?

The NHS had achieved considerable success in delivering efficiencies whilst maintaining services over recent years but this approach (e.g. pay restraint) could not be sustained indefinitely. Some of the fundamental challenges facing us:

Increasing Elderly population: we live longer, with complex health issues

Modern advances in treatments and technologies- transforming our ability to predict, diagnose and treat disease.

Increasing budget pressures due to the global recession.

NHS England have previously predicted that if we continue with the current model of care and expected funding levels, we could have a funding gap of £30bn a year by 2020/21 which will continue to grow and grow quickly if action isn’t taken.

The funding gap of £30bn supposes

• Uncontrolled rising demand

• No efficiency savings

• No additional funding

Therefore the three strands of a sustainable solution proposed in the 5 year forward plan are:-

• Major changes in the models of care recognising the need for a path between a single centrally determined model and “letting a thousand flowers bloom” i.e. a limited menu of solutions to suit local needs.

•Additional funding from Government of £8bn a year

Key themes in the NHS Five year forward view are:

Prevention

Radical upgrade in prevention and public health:

One in five adults still smoke. A third of us drink too much alcohol. A third of men and half of women don’t get enough exercise. Just under two thirds of us are overweight or obese. The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors.

New care models: Out of hospital care to be larger part of what the NHS does

Patients will gain far greater control of their own care – including the option of shared budgets combining health and social care.

NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.

England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care – the Multispecialty Community Provider. A further new option will be the integrated hospital and primary care provider – Primary and Acute Care Systems – combining for the first time general practice and hospital services.

Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.

The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.

The five year plan argues that there is nothing in their analysis that suggests that continuing with a comprehensive tax funded NHS is intrinsically un-doable. The five year plan argues that delivering on the transformational changes set out in the plan and the resulting annual efficiencies could – if matched by staged funding increases as the economy allows – could close the £30 billion gap by 2020/21.

The Mid Staffordshire NHS Foundation Trust Public Inquiry was announced on 9 June 2010 by the Secretary of State for Health (Andrew Lansley MP).

The Inquiry was established to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry was chaired by Robert Francis QC and considered why the serious problems at the Trust were not identified and acted on sooner and draw lessons to be learnt for the future of patient care.

The final report of the Inquiry was published on Wednesday 6 February 2013.

The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust provides detailed and systematic analysis of what contributed to the failings in care at the trust. It recognises that what happened in Mid Staffs was a system failure, as well as a failure of the organisation itself. Rather than proposing a significant reorganisation of the system, the report concludes that a fundamental change in culture is required to prevent this system failure from happening again, and that many of the changes can be implemented within the current system. It stresses the importance of avoiding a blame culture, and proposes that the NHS – collectively and individually –adopt a learning culture aligned first and foremost with the needs and care of patients.

The report identifies that the failures of the Trust was primarily caused by a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.

The report says ‘The story would be bad enough if it ended there, but it did not. The NHS system includes many checks and balances which should have prevented serious systemic failure of this sort. There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care. For years that did not occur, and even after the start of the Healthcare Commission investigation, conducted because of the realisation that there was serious cause for concern, patients were, in my view, left at risk with inadequate intervention until after the completion of that investigation a year later. In short, a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system’.

The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. That they did not has a number of causes, among them:

A culture focused on doing the system’s business – not that of the patients;

An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern;

Standards and methods of measuring compliance which did not focus on the effect of a service on patients;

Too great a degree of tolerance of poor standards and of risk to patients;

A failure of communication between the many agencies to share their knowledge of concerns;

Assumptions that monitoring, performance management or intervention was the responsibility of someone else;

A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession;

A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.

The Francis report makes 290 recommendations along the following themes:

1. Foster a common culture shared by all in the service of putting the pt first;

2. Develop fundamental standards and measures of compliance:

Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff

Provide professionally endorsed and evidence based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service;

Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards. Non-compliance with these standards should not be tolerated and any organisation not able to consistently comply should be prevented from continuing a service which exposes a patient to risk

To cause death or serious harm to a patient by non-compliance without reasonable excuse of the fundamental standards, should be a criminal offence.

These fundamental standards should be policed by the Care quality commission (CQC)

The merger of the regulation of care into one body – with Monitor responsibilities being absorbed by the CQC over time

3. Ensure openness, transparency and candour throughout the system underpinned by statute. Without this a common culture of being open and honest with patients and regulators will not spread. Including:

The “ duty of candour” – a statutory duty to be truthful to patients where harm has or may have been caused

Staff to be obliged by statute to make their employers aware of incidents in which harm has been or may have been caused to a patient

Trusts have to be open and honest in their quality accounts describing their faults as well as their successes

The deliberate obstruction of the performance of these duties and the deliberate deception of patients and the public should be a criminal offence

It should be a criminal offence for the directors of Trusts to give deliberately misleading information to the public and the regulators

The CQC should be responsible for policing these obligations

4. Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do;

a. Improved support for compassionate, caring and committed nursing

Entrants to the nursing profession should be assessed for their aptitude to deliver and lead proper care, and their ability to commit themselves to the welfare of patients

Training standards need to be created to ensure that qualified nurses are competent to deliver compassionate care to a consistent standard

Nurses need a stronger voice, including representation in organisational leadership and the encouragement of nursing leadership at ward level

Healthcare workers should be regulated by a registration scheme, preventing those who should not be entrusted with the care of patients from being employed to do so.

b. Stronger healthcare leadership

The establishment of an NHS leadership college, offering all potential and current leaders the chance to share in a common form of training to exemplify and implement a common culture, code of ethics and conduct

It should be possible to disqualify those guilty of serious breaches of the code of conduct or otherwise found unfit from eligibility for leadership posts

A registration scheme and a requirement need to be established that only fit and proper persons are eligible to be directors of NHS organisations.

So in summary, Francis report recommends making all those who provide care for patients – individuals and organisations – properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service. It also recommends development and sharing of ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.

Integrated care means care which is organised around the needs of individual patients. . Integrated care is not about structures, organisations or pathways – it is about better outcomes for service users.

There is now a clear consensus that successful integrated care is primarily about patient experience, although all dimensions of quality and cost-effectiveness are relevant

Further, integrated care is clearly not an end in itself, but is an essential tool to improve outcomes for individuals and communities.

In order to show why a smooth journey through the NHS is desirable, it is important to understand what a non-integrated system looks like and the experience that service users face when navigating through a fragmented system. For e.g. a diabetic patient may need services of the following: cardiology team, GP, practice nurse, renal team, diabetic team, diabetes specialist nurse, GP, practice nurse, vascular team, foot team, eye team, retinal screening team etc. This illustrates the complexity service users must navigate and, therefore, highlight the need of a more integrated system.

What are the problems with the current non- integrated care system?

Lack of ‘ownership’ for the patient and her problems, so that information gets lost as she navigates the system

Lack of involvement by the user/patient in the management and strategy of care

Poor communication with the user/patient as well as between health and social care providers

Treating service users for one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment

Lack of integration between health and social care- although decisions made in the social care setting affect the impact of health care treatment, and vice versa.

Is integrated care really needed?

The NHS is faced with the major challenges of using resources more efficiently and of meeting the needs of an ageing population in which chronic medical conditions are increasingly prevalent. The key task therefore is to implement a new model of care in which clinicians work together more closely to meet the needs of patients and to co-ordinate services and enable people with complex needs to live healthy, fulfilling, independent lives.

This model of integrated care would focus much more on preventing ill health, supporting self-care, enhancing primary care, providing care in people’s homes and the community, and increasing co-ordination between primary care teams and specialists and between health and social care

Integrated care is the only way to make health system sustainable in the long term by transferring care out of expensive hospitals and nursing homes in the community or even in patients own home.

What are the aims of integrated care?

Improved patient experience- by providing a seamless service reducing gaps and duplication in service

Improved patient outcomes i.e. improved quality

Improved cost effectiveness of care by improving system efficiency

Better experience for medical staff

However it is important to point out that more integrated care is not always the right answer to improving the patient’s experience and system efficiency. Integrated care also carries some risks, such as that of reducing competition, and incentives to improve quality.

How would you develop integrated care?

There are no general rules

Benefits depend on the specific design and approach to integrated care based on local circumstances

Learn from successful examples

Take patients view into account

Successful integration depend on which approach is used, how well it is implemented, and on features of the environment in which a provider is operating, including the financing system.

What are the barriers to integration?

Organisational boundaries- Primary or community care and secondary care or hospital care, social care (provided by LA) and health care- making it difficult for services to be properly coordinated. This leads to gaps and duplication of services. In a fully integrated system, patients’ needs not organisational boundaries would decide how care is provided

Lack of shared record keeping about a patient (GPs, hospital, nurses, social care workers)- hence patient and carers end up telling the same story to healthcare professionals. Lack of this info also cause poor care for e.g. a patient may turn up in ED and lack of info would not help

There are other barriers like:

Payment by Results provides hospitals with some incentives to keep patients in hospital rather than treating them in the community.

Service users choosing alternative providers: service users have freedom of choice regarding their elected place of care. However, this freedom can create deviations from the planned pathway of care and may cut across attempts to provide integrated care.

How can organisations enable integrated care?

Several measures could potentially mitigate these barriers. They may include:

Personal budgets

Make it easier for service users and carers to coordinate and navigate. This implies that every service user with long‐term or complex needs has easy access to a “care coordinator”, or federations of GP practices who can act as the coordinating point for all of their care.

Information is a key enabler of integrated care. Care records should be electronic and accessible at the point of care throughout the whole care journey, regardless of sector or provider

Can we do it?

NHS has spent the last decade or more in ensuring faster and easier access to GPs and consultants; reducing waiting times etc. and indeed vast progress has been made in these areas.

This was made to matter to the managers and clinical leaders- we need the same focus- the same urgency and importance being attached to patients with long term conditions, frail older people- and only when it matters that integrated care will become a reality.

What can we do to facilitate integrated care?

Clear policy directive as to why integrated care is important- we spend too much in acute hospitals, care to individual patient is poor and if we don’t change the system- it will never become a sustainable system

Sustained support for people seeking to develop integrated care locally- support in the form of using data analysing population need, project management,

Evaluation of integrated care initiatives- so that we can learn

To me it means that things are joined up, not fragmented into different parts with no one person informing all the relevant agencies about your needs and condition. Importantly also integrated care must include the persons wishes and needs, too often at the moment the person is left out of the loop! In my experience I am ‘told’ what I can and can’t have regardless of my needs and wishes. This is the same for many unfortunately.